Obstetrics simulation and training method and system

ABSTRACT

In the modern practice of obstetrics, the military is in the position of having experts in both simulation training for obstetric emergencies and teamwork training. The military has the potential to train better and provide the safest environment possible with these resources. Accordingly, an embodiment of the invention provides an obstetrics simulation system, comprising an articulating maternal birthing simulator. The maternal birthing simulator is a full size and full-body female having an intubeable airway with a chest rise component, a forearm having a medication receiving component, and/or a fetal heart sound component. Additionally, the maternal birthing simulator includes a head descent and cervical dilation monitor, a placenta positionable in at least two locations, two or more removable dilating cervices, and/or postpartum vulval suturing inserts.

I. FIELD OF THE INVENTION

An embodiment of the invention is in the field of obstetrics training ina variety of settings from small hospitals (or medical centers) to largemedical complexes.

II. BACKGROUND OF THE INVENTION

Because there is no greater emotional and significant event than thebirth of a child, physicians ensure that their practice patternsincorporate the most current and stringent evidence-based practices topromote patient safety. A recent report estimated that nearly 40% of allmaternal deaths in the United States could be avoided with betterobstetric care during emergencies. Berg C J, Harper M A, Atkinson S M,Bell E A, Brown H L, Hage M L, Mitra A G, Moise K J, Callaghan W M,Preventability of pregnancy-related deaths: Results of a state-widereview, Obstet Gynecol 2005, 106(6):1228-1234. In addition, obstetricsis the source of the greatest amount of money paid in legal claimsacross the Department of Defense with payments in the millions everyyear which are an obvious detriment to the military health care system'sreputation with patients and the general public.

III. SUMMARY OF THE INVENTION

An embodiment of the invention provides implemented technology andintegration of educational techniques with available resources in amanner that provides better training to a larger group of physicians andmedical personnel.

In the modern practice of obstetrics, the military is in the position ofhaving experts in both simulation training for obstetric emergencies andteamwork training. The military has the potential to train better andprovide the safest environment possible with these resources.

Accordingly, an embodiment of the invention provides an obstetricssimulation system, comprising an articulating maternal birthingsimulator. The maternal birthing simulator is a full size and full-bodyfemale having an intubeable airway with a chest rise component, aforearm having a medication receiving component, and/or a fetal heartsound component. Additionally, the maternal birthing simulator includesa head descent and cervical dilation monitor, a placenta positionable inat least two locations, two or more removable dilating cervices, and/orpostpartum vulval suturing inserts.

An eclampsia simulation component is provided in a cavity of thematernal birthing simulator, wherein the eclampsia simulation componenthas a motor, a drive shaft connected to the motor, and a cam connectedto the drive shaft. The cam engages and agitates an aperture within thecavity. The center of the cam is offset with respect to a center of theaperture. Specifically, rotation of the drive shaft and the resultingmovement of the cam shakes the cavity of the maternal birthing simulatorlaterally from side-to-side.

At least one processor is provided for receiving input from the maternalbirthing simulator, generating feedback based on the input, and sendingthe feedback to the maternal birthing simulator. The obstetricssimulation system further includes: a medical information (e.g., heartrate, temperature) display connected to the maternal birthing simulator,a video recording and playback system connected to the processor, and/oran audio system connected to the maternal birthing simulator. Moreover,a grading component is connected to the processor.

At least one embodiment of the invention provides a method, includingassembly of a simulation system having a simulator, a processor, and atleast one display. The simulation system is provided along withdocumentation to a plurality of medical facilities within a system.Training on the use of the simulator, different simulations, andcriteria for grading the performance on any given simulation is alsoprovided. The training includes team training for conducting simulationsusing the simulation system. The simulations include breech vaginaldelivery, umbilical cord prolapsed, eclampsia, neonatal resuscitation,operative vaginal delivery, postpartum hemorrhage, and/or shoulderdystocia.

More specifically, the breech vaginal delivery simulation assembles thebirthing mannequin and the birthing fetus in a breech position. Amedical staff is instructed that a patient feels pressure and has topush, wherein the patient is a birthing mannequin. The simulationobserves whether of breech presentation of a birthing fetus is diagnosedfrom a cervical examination of the birthing mannequin by the medicalstaff. It is further observed whether a delivery preparation isperformed by the medical staff, wherein the delivery preparationincludes pushing the head of the birthing fetus until a buttocks of thebirthing fetus begins to deliver in a sacrum anterior position. Thesimulation observes whether delivery maneuvers are performed by themedical staff. The delivery maneuvers are responded to with feedbackduring the simulation. The medical staff is debriefed and graded basedon observations and predetermined scoring criteria.

The umbilical cord prolapse simulation assembles the birthing mannequinand a mobile cart having a touch-screen monitor. A medical staff isinstructed that a patient's water has broken, wherein the patient is thebirthing mannequin. The simulation observes whether the medical staffrecognizes distress of the birthing fetus on the touch-screen monitorand observes whether the medical staff responds to the distress. If themedical staff waits for a vaginal delivery, the birthing fetus is keptwithin the abdomen of the birthing mannequin. The simulation observeswhether the medical staff transfers the birthing mannequin to theoperating room. The medical staff is debriefed and graded based onobservations and predetermined scoring criteria.

The eclampsia simulation assembles the birthing mannequin and mobilecart with at least one touch-screen monitor. The birthing mannequin hasa means for shaking to simulate a generalized seizure (e.g., theeclampsia simulation component). A medical staff is instructed that apatient has had a headache and it is getting worse, wherein the patientis the birthing mannequin. Moreover, the medical staff is instructedthat the patient's blood pressure is increasing. A simulated eclampticseizure is initiated by the simulator; and, the medical staff isobserved for whether or not they perform assessment and intervention ofthe simulated eclamptic seizure. The intervention includesadministrating medications and/or rolling the patient. The simulatedeclamptic seizure is continued. The medical staff is debriefed andgraded based on observations and predetermined scoring criteria.

The neonatal resuscitation simulation assembles the birthing mannequinand the baby simulator. The medical staff is observed for recognitionthat the baby simulator is not breathing and has a heart rate less than100 beats per minute. The simulation observes: whether the medical staffperforms bulb suction, drying and stimulation of the baby simulator,removal of wet linens, and positive pressure ventilation with oxygen,and whether the medical staff recognizes that the baby simulatorcontinues to not breath and the heart rate is less than 60 beats perminute. Moreover, the medical staff is observed for whether or not theyperform interventions, such as, for example, chest compressions,intubation, and/or administration of medications. The simulation alsoobserves: whether the medical staff examines an umbilical pulse for anactual heart rate, and whether the medical staff recognizes that thebaby simulator is breathing and the heart rate has increased if fiveminutes have passed since the performance of the bulb suction and themedical staff has intubated the baby simulator and administered at leastone dosage of epinephrine. The medical staff is debriefed and gradedbased on observations and predetermined scoring criteria.

The operative vaginal delivery simulation assembles the birthingmannequin, the mobile cart with at least one touch-screen monitor, and avacuum delivery fetus, which allows a vacuum delivery or a forcepsdelivery. The medical staff is observed for whether or not they performa cervical examination and recognize distress of the fetus. Thesimulation also observes: whether the medical staff counsels the patienton indications and risks of an operative vaginal delivery and whetherthe medical staff performs the operative vaginal delivery. The fetus ispushed to facilitate the operative vaginal delivery. The medical staffis debriefed and graded based on observations and predetermined scoringcriteria.

The postpartum hemorrhage simulation assembles the birthing mannequinwith a postpartum hemorrhage uterus insert, and the mobile cart with atleast one touch-screen monitor. Bleeding of the birthing mannequin issimulated; and, the uterus of the birthing mannequin is not allowed tofully inflate. The simulation observes whether the medical staffperforms assessments and maneuvers. The maneuvers include a fundalmassage, inspection of the cervix and/or vagina for lacerations, manualclearing of the uterus, and/or administration of medications. If themaneuvers include the fundal massage, the simulating of the bleedingcontinues. The medical staff is debriefed and graded based onobservations and predetermined scoring criteria.

The shoulder dystocia simulation assembles the birthing mannequin andmobile cart with at least one touch-screen monitor. The medical staff isinformed that the patient is having a contraction and feels that she hasto push, wherein the patient is the birthing mannequin. The head of thefetus is pushed until the head delivers; and, the fetus is restituted,wherein the shoulder of the fetus is anterior. Traction on a harness isapplied and the shoulder is not allowed to deliver. A timer is activatedto measure the head-to-body delivery interval. The simulation observeswhether the medical staff recognizes shoulder dystocia and performsmaneuvers. Maneuvers are responded to with feedback. If the medicalstaff delivers a posterior arm of the fetus, the fetus is allowed todeliver. If the medical staff does not deliver the posterior arm of thefetus, the medical staff is allowed to perform a Zavenelli maneuver ordiscontinue delivery. The timer is stopped; and, the medical staff isdebriefed and graded based on observations and predetermined scoringcriteria.

Given the following enabling description of the drawings, the apparatusshould become evident to a person of ordinary skill in the art.

IV. BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates an exemplary arrangement according to the inventionwith a simulator and equipment connected to the simulator to displayinformation relevant for the simulation.

FIGS. 2 and 3 illustrate an exemplary monitor arrangement and associatedequipment to run the simulation in conjunction with the simulator.

FIG. 4 illustrates an exemplary arrangement according to the inventionin a medical setting.

FIG. 5 illustrates a cart with some peripheral equipment attached.

FIGS. 6A-6C are screen shots illustrating a grading system.

FIGS. 7A-7B illustrate scoring sheets.

FIG. 8 illustrates a debriefing questionnaire.

FIGS. 9A-9C illustrate an eclampsia simulation component

FIG. 10 is a flow diagram illustrating a breech vaginal deliverysimulation.

FIG. 11 is a flow diagram illustrating an umbilical cord prolapsesimulation.

FIG. 12 is a flow diagram illustrating an eclampsia simulation.

FIG. 13 is a flow diagram illustrating a neonatal resuscitationsimulation.

FIG. 14 is a flow diagram illustrating an operative vaginal deliverysimulation.

FIG. 15 is a flow diagram illustrating a postpartum hemorrhagesimulation.

FIG. 16 is a flow diagram illustrating a shoulder dystocia simulation.

V. DETAILED DESCRIPTION OF THE DRAWINGS

An embodiment of the invention combines simulation training forobstetric emergencies and TEAMSTEPPs training. Simulation trainingprovides a platform with which to train and test both soldiers andphysicians in a nearly endless variety of scenarios. It allows forphysicians, nurses, and ancillary staff to train for uncommon yetlife-threatening emergencies with no risk to a patient or her unbornchild. In at least one embodiment, simulating obstetric emergencies doesnot require extremely expensive mannequins and software to accomplish.The equipment is also portable and can be used on any labor and deliveryward so that it is accessible to those who need the training most. Anembodiment of the invention includes a comprehensive curriculum withsimulations and evaluation tools that objectively evaluate staff(physicians, nursing, support personnel) performance during obstetricemergencies. To accompany the curriculum, a mobile obstetric simulatoris used that can be placed at specific training sites. To ensure thatthe focus is improving the entire team approach to patient care, theevaluation tools are designed to also evaluate teamwork during theemergencies based on the TEAMSTEPPs training model.

TEAMSTEPPs training, which is derived from lessons learned from theairline industry's extremely successful safety protocols, teachesphysicians, nurses, and other personnel to work together as a team. Theframework in which the tenets are implemented results in culture changethat promotes teamwork rather than adversarial relationships.

As stated previously, the invention in at least one embodiment combinesthe ongoing TEAMSTEPPs training model with an obstetric emergenciessimulator that will be placed at each specified medical trainingfacility. This allows for regular training to be conducted on severallevels for patient safety. By training resident and staff physicians,the care of patients will improve when the unpreventable obstetricemergencies, such as a shoulder dystocia which is when the fetalshoulder becomes lodged behind the symphysis and will not spontaneouslydeliver, occur. In addition, the mobile simulator allows for emergencydrills on the actual labor and delivery units that will involve multiplelevels of care, including nursing, physicians, and ancillary staff. Thissimulation training will provide a safe, no risk environment where bothtechnical performance as well as progress on teamwork is objectivelyevaluated and improved, and any systems problems identified before atrue emergency or poor outcome occurs.

To accomplish this, an embodiment of the invention is implemented toprovide training where it can have the greatest effect. This means atlarge training facilities that not only have a high number ofdeliveries, but are also training residents who will become the futurestaff. By improving the performance of these physicians, the largestimmediate impact for patients as well as on the facilities that thegraduating residents are assigned to will occur. Data on both technicaland teamwork performance will be collected from these large trainingfacilities.

An embodiment of the invention has far reaching effects on how militaryand civilian labor and delivery units function and the care theyprovide. Not only is there a heightened focus on patient safety, butalso the ability for the commands to objectively measure technical andteamwork performance during simulated emergencies with no risk topatients or their infants. In addition, this training provides atangible example to the civilian sector and the patients that themilitary health care system is committed to improving patient safety.

FIG. 1 illustrates a simulator 100 such as the Gaumard Scientific S555Noelle simulator that is connected to a laptop 140 and a second computer150 (illustrated in FIGS. 2 and 3). These two computers 140, 150 in atleast one embodiment together run the simulation and the responses todifferent treatments provided by the medical teams undergoing asimulation. The second computer 150 in at least one embodiment drivesthe displays 152 to provide medical information such as heart rate andblood pressure, that is typically present in a medical setting and toprovide additional information as to the status of the simulated patientin view of the simulation stage and treatment to that time. The camera190 (illustrated in FIG. 2) is provided to record a particularsimulation to assist with replay and to allow participants to viewthemselves in action during the course of the simulation as part of thedebriefing.

As illustrated in FIG. 1, the simulation is setup for a team of medicalprofessionals to work together during the course of the simulation toallow for better understanding of each member's role and where thedifferent participants may be able to offer assistance or knowledge asthe situation may dictate. FIGS. 2-5 illustrate different aspects of theinvention.

One particular implementation of the system includes the followingcomponents, which one of ordinary skill in the art will appreciate basedon this disclosure that specific reference to particular manufacturersand products are to better identify the desired characteristics and thuscan be substituted for by different equipment if desired:

1. custom articulating camera arm;

2. lockable and mobile security cart 120 (30W SM/FG 5″ castors) forhousing the computer equipment and peripherals to better facilitatestorage and convenience of use of the system with the mannequin in mostimplementation be stored in a separate container such as a hard case ora bag;

3. flat panel mount double for holding the medical monitors 122;

4. universal keyboard and mouse;

5. 30W enclosed cart drawer SIL/M;

6. a camcorder with at least a 30 GB hard drive such as the JVCCamcorder JVC GZMG255US;

7. a JVC Everio CU-VD10 Share Station—DVD-RW drive—Hi-Speed USB;

8. a HP DJ 460c 17/6PPM 8.5×14 or other similar printer 180;

9. a 24-pad audience response system (CPS) IR System (Number each set1-24) such as the elnstruction Corp. Classroom Performance System;

10. an IPOD NANO™ 2 GB Silver or other audio player (MP3 player) with aprotective case for playing sounds during the course of the simulation;

11. V10 NB speakers USB-PC MAC USB VOL CTRL or other similar speakers;

12. maternal & neonatal birthing simulator (such as the GaumardScientific S555 Noelle simulator) with a full size articulatingfull-body female, intubeable airway with chest rise, IV arm forreceiving medications and other fluids, removeable stomach cover,practice leopold maneuvers, multiple fetal heart sounds, automaticbirthing system, measure head descent and cervical dilation, multipleplacenta locations, replaceable dilating cervices, practice postpartumsuturing on vulval inserts, one articulating birthing baby withplacenta, PEDI® blue neonatal simulator with SmartSkin™ (LED lights willturn blue and respond to positive pressure ventilation), and apostpartum hemorrhage and palpation module that has NOELLE S550.100 withPEDI® Blue full term neonate (in an embodiment of the invention, thedelivery motor is removed);

13. two 17 inch touch screen monitors for fetal heart rate tracing anddisplaying maternal vitals (present scenarios will be loaded on thecomputer);

14. one computer (or other processing equipment) (although a laptopcould be substituted for this computer instead of a desktop computerbeing used as illustrated) to control monitors and communicationwirelessly with a laptop;

15. one laptop computer with wireless communication to the firstcomputer (although a desktop computer could be substituted);

16. a boggy uterus with blood capability (PPH);

17. an articulating baby;

18. elevating pillow for leopold maneuvers;

19. an articulating fetal baby (operative vaginal delivery fetus),umbilical cord (in an embodiment of the invention, a pulse is felt inthe umbilical cord), and placenta for vacuum delivery;

20. a Eclampsia model; and

21. a CPS debriefing/grading system having individual keypads (IRsystem), labeled keypads (e.g., physician grader 1, physician grader 2,primary nurse), and on-screen anonymity.

FIGS. 6A and 6B illustrate an example of on-screen anonymity. Eachgrader (e.g., Physician 1, Physician 2, Nurse 1, Nurse 2) inputs scoresinto the system. For example, a scoring factor for the eclamptic seizuresimulation is whether the provider recognizes the situation as aneclamptic seizure (FIG. 6A; A=Yes, B=No). After all of the graders haveinput their scores, the combined scores are displayed, wherein thegraders remain anonymous (FIG. 6B; five graders scored a “Yes”, threegraders scored a “No”). As illustrated in FIG. 6C, reports can beproduced in order to view the scoring input by graders for a specificscoring factor (e.g., “Calls for additional help”).

There are a variety of potential problems that the system will be ableto address for a variety of reasons. Drawbacks to medical simulation inthe past have included a lack of resources required to develop trainingscenarios, staffing to implement the training, and the need forvalidation of training methods in an objective manner. In addition, theequipment itself is often very expensive to purchase and maintain andmay require a large amount of space to store which is difficult tojustify if it is only needed on a monthly basis. The present systemaddresses all of these issues. While labor and delivery units are bytheir very nature busy, fast-paced environments, the staffs aretypically committed to patient safety. The equipment for the presentsystem is not only relatively inexpensive compared to some simulationproducts, where a single mannequin or simulator may cost over $100,000,and may be easily stored so that it will not be necessary for smallerfacilities to take up an entire exam room or other space in order tomaintain a state-of-the-art simulator training program. In addition, itsportable design allows it to be deployed to small facilities and evenoverseas for humanitarian missions if needed or desired.

The following provides a background and overview of the simulationsystem. Goals of the mobile obstetrics emergency simulator includeimprove patient safety, improve teamwork and technical performance,identify and correct systems issues unique to each labor and deliveryunit. Another goal is to create a mobile platform that accomplishes thefollowing: run simulations on actual labor and delivery units, provide astandardized curriculum, evaluate both teamwork and technicalproficiency, integrate a no-fault debriefing tool, be able to monitorprogress over time, and inexpensive. Other goals include: 1) providesimulation training for all levels of providers (also referred to hereinas physicians, residents, nurses, staff, participants, team, and alliedhealth personnel) to improve cognitive, technical and teamwork skills ina “no-risk” to the patient environment, and 2) improve patient andcasualty outcomes and patient safety in all environments.

Differences between Central Simulation Committee (CSC) and TMAcurriculum include: TMA curriculum is specific to the labor and deliveryteam, CSC grading is done online and is directed atresidents/individuals, CSC Obstetric simulations are different becauseassistants are not necessarily available, and equipment is essentiallythe same for both and is used for both at dual institutions.

An embodiment of the invention provides for the running of simulations.Specifically, a method sets up the room, briefs the initial participanton the clinic scenario, and runs the simulation drill. Moreover, thedebriefing is conducted on the CPS system, the evaluation is filled outon the CPS system, and the evaluation forms are downloaded. Entities aredebriefed, e.g., the Command, pediatrics, anesthesia, labor and deliverystaff, obstetrics/gynecology, and family medicine.

The curriculum of an embodiment of the invention includes a breechvaginal delivery, umbilical cord prolapsed, eclampsia, neonatalresuscitation, operative vaginal delivery, postpartum hemorrhage, andshoulder dystocia. The simulation examples were chosen and described inorder to best explain the principles of the invention and the practicalapplication, and to enable others of ordinary skill in the art tounderstand the invention for various embodiments with variousmodifications as are suited to the particular use contemplated.

Breech Vaginal Delivery Simulation

The following description provides a curriculum example for a breechvaginal delivery simulation. One of ordinary skill in the art willappreciate based on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for breech vaginal delivery includes a 26year-old G3P2002 at 36+0 weeks, who is presented to the triage room ofLabor and Delivery. On exam, the fetus is in a breech presentation withthe buttocks visible at the introitus without pushing. The fetal heartrate is 150 beats per minute. The estimated weight is 7 lbs. The womanstates she has had two vaginal deliveries of 8 lb infants and does notwant a cesarean section. In an alternate clinical scenario, a 31 yearold G1 P0 at 35+4 weeks is presented to labor and delivery. She reportsfeeling a lot of pressure and that she began leaking “brown fluid” about30 minutes ago when she thinks her water broke. The fetal heart rate is140 beats per minute.

In an embodiment of the invention, basic instructions for participantsinclude: treating the scenario as real as possible, usingmask/gloves/gown as needed, requesting assistance if needed, ignoringthe camera, and do not cut the perineum, but indicate if you would makean episiotomy. Other instructions include: retrieving any medicationsthat you need during the scenario, but do not open them to actually givethem in the room, and you may move the patient to the operating room andeven to the operating room table if needed, but you do not need tophysically open up the instrument sets.

The simulator utilized for the breech vaginal delivery example is theNOELLE birthing mannequin with the standard birthing fetus that isplaced in a breech position although other simulators could be used. Inaddition, the touch-screen monitors that are attached to the mobile cartmay be used. The room is set up similar to a delivery room. Thesimulator is on an examination table, gurney, or bed with the lowertorso draped. A delivery table is available with basic equipment. Ifvideotaping is performed, the camera can be held by a staff member, atripod, or the camera arm on the cart.

Equipment utilized for the breech vaginal delivery includes the birthingsimulator, a standard delivery table (e.g., bulb suction, Kelly clamps,scissors), video camera, Piper forceps, fetal monitor, and audio player(e.g., MP3 player). The vital sign software of the fetal monitor is usedto demonstrate worsening maternal status during the simulation.Incorporating this into the training adds to the realism of the scenarioas this is heard by the providers during the simulation. As describedfurther below, after starting up the software, files are loaded atspecified time intervals. Personnel utilized for the breech vaginaldelivery includes staff to control the fetus and maternal mannequin,assistants to assist with maneuvers, and/or staff to film the procedure.Staff member(s) could also be utilized as live actor(s) accompanying thepatient to add realism and play the part of a family member to addstress/distraction/confusion in the simulation.

Tips to be given to the simulation participants include: do not leavethe Piper forceps out in view; do not put the elevating pillow into theabdomen for this delivery as it will make things very difficult; and,remove the cervix that comes with the model as it generally will hold upthe fetus and it is not needed for this simulation. Other tips include:use plenty of lubrication for the fetus (e.g., silicone lubricant,sonogram gel); and, only simulate an episiotomy if you feel that one isnecessary and do not actually cut the mannequin.

Thus, in an embodiment of the invention, a case flow for the breechvaginal delivery includes setting up the NOELLE simulator, turning fetalmonitors on, loading the desired scenario, and clicking “Update”. Theinitial provider is briefed on the clinical scenario and the providerenters the room. The primary staff tells the provider that the patientfeels pressure and has to push. The provider addresses the patient,performs a cervical examination, and diagnoses the breech presentation.The providers are given a chance to counsel the patient about a breechvaginal delivery before pushing the baby out if they begin to discussthis. If the providers do not counsel the patient spontaneously, theperson controlling the fetus asks “are babies supposed to come outbreech?” to give them another opportunity to counsel the patient.

The fetal head is pushed until the buttocks begins to deliver in thesacrum anterior position. The providers are allowed to prepare fordelivery of the breech fetus. As the breech delivers, the providersrecognize the breech presentation and begin maneuvers. Maneuvers areresponded to with feedback if they ask questions; and, the fetus iscontinually pushed to deliver. When the providers have completed thedelivery, they are told that the scenario is over.

In an embodiment of the invention, if the providers insist on a cesareansection, the fetus is pushed out so that they must do the delivery. Theproviders are given a short amount of time to prepare for the delivery(e.g., call pediatrics, find Pipers). After the scenario is over, all ofthe participants are gathered together in the delivery room with themobile obstetrics simulator. Clickers are handed out to the appropriatestaff participants. The clickers are labeled for the physician grader 1,primary physician, primary nurse, and so on. The CPS system is opened;and, the debrief for the appropriate scenario is loaded. The basicassumption is reviewed with the team; and, the teamwork debriefing isconducted. After the teamwork debriefing, critical actions for thesimulation are reviewed with the team. The team members are asked forany lessons learned and responses are recorded so that they can beimplemented on the labor and delivery ward if needed. The labor anddelivery team is dismissed; and, the provider tasks and performancegrading is opened for the simulation scenario. The provider tasks andperformance grading is gone through with all of the graders (e.g., 2physicians and 2 nurses who observed the simulation). The teamworkdebriefing, provider tasks, and performance grading is exported.

The following are potential factors to consider when scoring theproviders on the vaginal breech simulation: calls for help, suggestionto move to the operating room, allowing breech to deliver to umbilicuswith maternal pushing, episiotomy, delivery of leg (splint medialthighs, parallel to femur and sweeps laterally), repeat on opposite leg,placement of moist towel on fetal trunk, fingers on bones and groins,gentle downward traction with sacrum anterior, 90°-180° rotation todeliver arms, delivery of arms (sweeping in long axis of bone downward),and rotation and repeating with second arm. Examples of formats forvaginal breech simulation scoring sheets are illustrated in FIG. 7.

Regarding use of the Piper forceps, potential grading factors include:using the forceps after the shoulder and arms have been delivered andthe head is in the pelvis with the chin posterior, holding the infant ina towel (infant should not be held above the horizontal plane), applyingthe left blade first, carrying the infant's body toward the mother'sright side, assuming a kneeling position while the left blade is held bythe left hand with the handle below the patient's right thigh andbeneath the body of the infant (the toe of the blade is guided into thevagina with the provider's right hand), sweeping the handle in an arcdownward and towards the midline while the toe of the blade passes intothe pelvis along the side of the infant's head to the right ear, andintroducing the right blade in a similar fashion (if resistance is met,the toe is introduced more posteriorly and wandered along the side ofthe head). Other potential grading factors regarding the use of piperforceps include: locking the shanks (the infant is allowed to straddlethe forceps), applying downward traction in the direction of the handlesuntil the chin appears at the outlet, elevating the handles withtraction to conform to the curve of the pelvis, preserving the headflexion (the body rests on the shanks of the forceps while the neck issplinted by the fingers of the provider's splint neck left hand), andperforming an extraction with the handles close to horizontal whiledelivering the head with the forceps still in place.

Regarding performance of the Mauriceau-Smellie-Veit maneuver, potentialscoring factors include: applying the index and middle finger over themaxilla to flex the head while the body rests on the palm and forearm,hooking two fingers of the other hand over the neck while grasping theshoulder and applying gentle downward traction, and applying suprapubicpressure by an assistant. The skill and safety of the physician inperforming the breech vaginal delivery are other scoring factors.

In at least one embodiment, teaching points and critical actionsdiscussed in debriefing include: knowledge of risk factors for anemergency vaginal breech delivery, ability to execute the criticalactions as outlined by the scoring factors, and review of maneuvers asdescribed by the scoring factors. Demonstrations are preformed on themannequin during the debriefing process. Furthermore, potentialcomplications are discussed, such as fetal head entrapment. The actualsimulation takes approximately 5-7 minutes to complete. Debriefing takesapproximately 10-15 minutes depending on the team's performance.

Umbilical Cord Prolapse Simulation

The following description provides a curriculum example for an umbilicalcord prolapse simulation. One of ordinary skill in the art willappreciate based on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for an umbilical cord prolapsed includesa 25 year old G1 P0 at 40+3 weeks, who is presented to labor anddelivery with a chief complaint of regular uterine contractions. Onexamination, she is noted to be C/3/−3 VTX with intact membranes. Thefetal heart rate tracing (FHRT) has been reassuring. The patient'shusband informs the providers that his wife feels like her water broke.An alternative clinical scenario involves a 33 year old G2P1001 at 37+0weeks, who was admitted last night for therapeutic rest and givenmorphine sulfate approximately 8 hours ago. The FHRT has remainedreassuring and she is now beginning to feel more pressure and would liketo be evaluated.

The simulator utilized for the umbilical cord prolapsed example is theNOELLE birthing mannequin although other simulators could be used. Inaddition, the touch-screen monitors that are attached to the mobile cartare available for use. The room is set up similar to a delivery room.The simulator is on an examination table, gurney, or bed with the lowertorso draped. A delivery table is available with the basic equipment.Additional equipment includes a Simulating High Acuity Deliveries (SHAD)birthing simulator, chronograph, fetus in vertex position with umbilicalcord prolapsed through, cup of water to pour on the perineum, pads tosimulate amniotic fluid, and a fetal monitoring system.

Specifically, in at least one embodiment, a case flow for the umbilicalcord prolapsed simulation includes setting up the mannequin and openingthe fetal monitoring software. The file “Umbilical Cord Prolapse” isopened and the fetal heart rate tracing is updated. The initial provider(e.g., nurse or physician) is briefed on the clinical situation prior toentering the room. The provider enters the room and is informed that thepatient's water may have just broken. The provider recognizes fetaldistress on the monitor and begins evaluation. The fetal monitor is upand running and demonstrates a significant bradycardia.

The team is allowed to respond to the umbilical cord prolapse. If theytry to wait for a vaginal delivery, the baby is kept in the abdomen ofthe simulator. The team is allowed to take the patient to the operatingroom and transfer her to the operating room table. The scenario isstopped when the patient has been transferred to the operating roomtable. The team returns to the room with the mobile obstetrics simulatorfor the debriefing.

During debriefing, in at least one embodiment, clickers are handed outto the appropriate staff participants and the CPS system is opened. Thedebrief for the appropriate scenario is loaded and the basic assumptionis reviewed with the team. After the teamwork debriefing, criticalactions for the simulation are reviewed with the team. The team membersare asked for any lessons learned, which are recorded so they can beimplemented on the labor and delivery ward if needed.

The labor and delivery team is dismissed and the provider tasks andperformance grading for the simulation scenario are opened and reviewedwith all of the graders. The teamwork debriefing, provider tasks, andperformance grading are exported.

The following are potential factors to consider when scoring theproviders on the umbilical cord prolapse simulation: counseling patientregarding the finding of a prolapsed cord, calling for pediatrics,calling for anesthesia, keeping a hand in the vagina to elevate thefetal head (the entire time it takes to get the patient into theoperating room), calling for a scrub technician, the amount of time todiagnose the umbilical cord prolapse from the time the first personentered the room, and the amount of time to get the patient into theoperating room from the time the cord prolapse was diagnosed.

In an embodiment of the invention, teaching points and critical actionsto discuss in debriefing include: understanding and verbalizing riskfactors for umbilical cord prolapsed, executing the critical actions asoutlined in the scoring factors, and evaluating the emergency teamresponse times and how the situation was communicated. The actualsimulation itself only takes approximately 5-7 minutes to complete.Debriefing and additional practice with the maneuvers takesapproximately 10-15 minutes.

In at least one embodiment, when the umbilical cord is palpated in thevagina, the examiner does not remove their hand, but rather attempts toelevate the presenting part off of the umbilical cord. The patient istaken immediately to the operating room for an emergency cesareandelivery. The initial examiner's hand remains in the vagina until thebaby is delivered by cesarean section. If there is any delay inperforming the cesarean section, terbutaline is administered to decreaseuterine contractions, or the bladder is filled with 500 mL of fluid toelevate the presenting part off of the cord.

Eclamptic Seizure Simulation

The following description provides a curriculum example for an eclampticseizure simulation. One of ordinary skill in the art will appreciatebased on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for the eclamptic seizure simulationincludes a 19 year old G1 P0 at 38+4 weeks who was admitted in activelabor this morning. Her prenatal course was uncomplicated, with theexception that her cervical examination was C/4/−2 just before shereceived her epidural about 30 minutes ago. She now reports a new onsetheadache and her nurse would like her to be evaluated. An alternateclinical scenario involves a 37 year old G6P5005 at 39+0 weeks with aprenatal course complicated by chronic hypertension with baselineproteinuria. She was admitted for augmentation of labor this morning andis now on 10 miu/min of oxytocin. Her cervix was just examined and wasC/5/−1. The nurse would like the fetal heart rate tracing to bereviewed.

In at least one embodiment, the simulator that is utilized for theeclamptic seizure simulation is the NOELLE birthing mannequin althoughother simulators could be used. The birthing mannequin includes aninternal eclampsia modification, which causes the mannequin to shake andsimulate a generalized seizure when activated. The seizure continues aslong as the button is held down and stops when the button is released.

The delivery fetus, in at least one embodiment, is placed into thematernal abdomen with the cervix. The abdominal cover is replaced. Thus,if the provider checks the patient, they will know that the patient isonly a few centimeters dilated. The fetal heart rate monitors are usedto demonstrate variable decelerations during the eclamptic seizure.Incorporating this into the training by using it to produce fetal heartrate (FHR) changes during and after the seizure adds to the realism ofthe scenario as this is heard by the resident during the simulation. Inorder to do this, after starting up the software, the file “EclampsiaInitial” is loaded; and, the “Update” button for the fetal monitors isclicked before the provider enters the room. The “Eclamptic Seizure” and“Update” button are clicked when the patient begins to have a seizure.The NOELLE birthing mannequin has an intravenous therapy (IV) withtubing going to an IV bag taped to her arm.

In an embodiment of the invention, the providers include staff (playspart of the nurse) to control the fetus and maternal mannequin, andstaff to film the procedure (or a tripod or camera arm mounted on thecart is used). Staff member(s) could also be utilized as live actor(s)accompanying the patient to add realism and play the part of a familymember to add stress/distraction/confusion in the simulation.

The case flow of the eclamptic seizure simulation includes setting upthe mannequin, turning on the fetal monitoring software, loading the“Eclampsia Initial” software, setting the fetal monitors to on, andclicking “Update”. The initial provider is briefed on the clinicalscenario; and, the provider enters the room. The providers are allowedto introduce themselves and they are informed that the birthingmannequin has had a headache for approximately 24 hours and it isgetting worse. The staff playing the part of the patient's family memberinforms the resident that “her blood pressure readings have been goingup. The last one was 155/100.” The button for the eclamptic seizure ispushed and the timer is started. “Eclamptic Seizure” is opened in thefetal monitoring software and “Update” is clicked. The providersrecognize the complication and begin assessment and interventions,including calling for assistance. The team is allowed to administermedications, roll the patient, or do whatever other interventions theydesire. The seizure is continued for approximately 4 minutes, regardlessof what interventions are undertaken. When the seizure is over, theproviders are given approximately 30 seconds to discuss continuingmagnesium medications and then they are informed that the scenario isover.

In at least one embodiment, the providers are not given any more patienthistory than what was given before they walked into the room. If theproviders ask whether or not the patient has proteinuria, they are toldthat the patient's admission urinalysis showed 2+ protein. If medicationdoses are incorrect, this is addressed in the debriefing. A cesareansection is not done unless the bradycardia lasts for more thanapproximately 10 minutes after the seizure. An emergency cesareansection is not required after an eclamptic seizure. Eclamptic seizuresare generally self-limited to approximately 2-4 minutes. Magnesiumshould not be given as an IV bolus, but rather over approximately 15-20minutes.

In an embodiment of the invention, clickers are handed out to theappropriate staff participants, the CPS system is opened, and thedebrief is loaded for the appropriate scenario. The basic assumption isreviewed with the team; and, the teamwork debriefing is conducted. Afterthe teamwork debriefing, critical actions are reviewed for thesimulation with the team; and, the team members are asked for anylessons learned to be recorded and potentially implemented on the laborand delivery ward if needed. The labor and delivery team is dismissed,the provider tasks and performance grading for the simulation scenariois opened and reviewed with all of the graders (e.g., up to 2 physiciansand 2 nurses who observed the simulation). The teamwork debriefing,provider tasks and performance grading are exported.

The following are potential factors to consider when scoring theproviders on the eclamptic seizure simulation: recognizing the situationas an eclamptic seizure, calling for additional help (e.g., nursing orphysician), calling for anesthesia, moving the patient to a lateraldecubitus position, inserting a tongue blade into mouth, placingsupplemental oxygen on the patient, placing a pulse oximeter on thepatient, administering magnesium sulfate to control the seizure (e.g.,correct dose of 6 grams given through an IV over 15-20 minutes, given asa bolus (<15 min)), administering diazepam to control the seizure (e.g.,correct dose of 5 grams given through an IV over 15-20 minutes, given asan IV push), and administering hydralazine to control hypertension(e.g., correct dose of 5-10 mg given through an IV push), administeringlabetaolol to control hypertension (e.g., correct dose of 20-40 mg giventhrough an IV push), and deciding to deliver by cesarean section.

In at least one embodiment, other potential scoring factors include:addressing the eclamptic seizure in a timely manner, remaining calmduring the eclamptic seizure simulation, communicating well withassistants during the simulation, overall performance of the providerduring the eclampsia scenario, and preparedness of the provider for theeclampsia complication. Points to discuss during the debriefing include:knowledge of medications to treat eclampsia, understanding andverbalizing risk factors for preeclampsia and eclampsia, recognitionthat eclamptic seizures are generally short (e.g., lasting 2-4 minutes)and magnesium sulfate is continued afterwards to prevent furtherseizures, ability to execute the critical actions as outlined by thescoring factors, reviewing medication dosages and route ofadministration, and recognition that the fetal heart rate tracinggenerally recovers within approximately 10 minutes of the seizure (andrecognition not to rush into a cesarean section on an unstable patient).The actual simulation itself only takes approximately 5-7 minutes tocomplete; approximately 10-15 minutes are allowed for the debriefing andreviewing the best practices and safety points.

In an embodiment of the invention, initial treatment of eclampsia isaimed at stabilizing the mother and controlling the seizures. Thedefinitive treatment for the underlying disease is the eventual deliveryof the fetus. During the acute event, however, the mother takesprecedence as the fetus does better when the mother is stabilized. Aprocess for treating eclampsia includes calling for assistance (e.g.,nursing staff, anesthesiologist, additional obstetricians, and/orpediatrician as delivery may be required after the seizure has beencontrolled). To protect the airway, the patient is rolled to her leftside and a padded tongue blade is placed in the patient's mouth ifpossible. This helps prevent aspiration should the patient vomit whileshe cannot protect her airway. Medication is administered to controlseizures, for example, magnesium sulfate and diazepam. Exemplary dosesfor magnesium sulfate are 2-4 grams IV push for 15 minutes to a maximumof 6 grams. Exemplary doses for diazepam are a 5 mg IV push, repeated asneeded up to 20 mg total. This medication controls or breaks seizureactivity in more than 80% of patients within 5 minutes (Delgado-Escueta,1982)). To treat severe hypertension (i.e., >160/110) and to decreasethe risk of intracerebral hemorrhage, the following exemplarymedications and doses can be used to acutely decrease the patient'sblood pressure. Hydralazine is administered for a 5 mg IV push, then5-10 mg for 20 minutes as needed. 10-20 mg of labetalol is administeredthrough an IV, then the dose is doubled every 10 minutes as needed up toan 80 mg dose with a total cumulative dose of 220 mg. After theeclamptic seizure has resolved, patients receive magnesium sulfateseizure prophylaxis (4-6 gram via IV over 15-20 minutes followed by 2grams/hour for at least 24 hours).

The definitive treatment of the disease is delivery, but this does notnecessarily mean a cesarean section must be performed immediately.Induction of labor is reasonable after the seizure has been controlledin the term or near-term fetus when the cervix is favorable, the fetusis in a vertex position, and any fetal distress has been resolved. Thepatient is monitored for development of complications. Complications tobe monitored include, for example, disseminated intravascularcoagulopathy with resulting hemorrhage, acute renal failure, pulmonaryedema, intracerebral hemorrhage, cardiac arrest, liver rupture, and/ortransient blindness (Lopez-Llera, 1992). Severe FHR decelerations of 3-5minutes are commonly seen with eclamptic seizures. This degree of fetaldistress does not prompt emergency delivery. The emphasis is on maternalstabilization, as outlined above, as the FHRT improves as the motherimproves.

Neonatal Resuscitation Simulation

The following description provides a curriculum example for a neonatalresuscitation simulation. One of ordinary skill in the art willappreciate based on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for a neonatal resuscitation simulationinvolves calling providers to help resuscitate an infant that was bornless than a minute ago via a vacuum delivery for fetal distress that wascomplicated by a shoulder dystocia that required delivery of theposterior arm to accomplish delivery. The infant is the product of a 26year old G2P1001 at 38 and 5/7 weeks, GBS+. In an alternate clinicalscenario, a 25 year old G3P2002 at 39+3 weeks is presented complainingof an urge to push. The provider is not given time to get her chart, butthe patient says that her prenatal course was uncomplicated. The patientis taken quickly to a labor room and precipitously delivered. The staffin the room requests that someone come to help resuscitate the baby. Ifthe neonatal resuscitation scenario is run in combination with adelivery scenario, then the clinical scenario from the other simulationis used.

Basic instructions are given to the participants (as described above).The simulators used for the neonatal resuscitation example include theNOELLE birthing mannequin and the resuscitation baby that comes with themannequin although other simulators could be used. The resuscitationbaby is also referred to as the PEDIBIue; this infant is slightly largerthan the average newborn. For this simulation, the providers arereminded that: the baby can demonstrate central and peripheral cyanosis;the baby will not breathe spontaneously; and, the cyanosis will resolvewhen ventilations are done in the normal or high range within about 20seconds (so the ventilations will have to be reset during the scenario).The providers are also reminded that the PEDIBIue can be somewhatdifficult to intubate because the airway is very anterior; the infant'sheart rate will not be able to be controlled in the umbilical cordremnant with the red bulb; and, the PEDIBIue can monitor the forcegenerated with both respirations and CPR (this is a potential gradingfactor).

In a neonatal resuscitation only simulation, the infant simulator isplaced on an infant warmer in the delivery room and is left uncovered.The infant warmer is stocked with the usual instruments and medicationsused in a delivery/resuscitation. This does not need to be checkedbefore the simulation. If the neonatal resuscitation is combined withanother simulation, the PEDIBIue simulator is placed on the warmer withthe head towards the end of the warmer (i.e., in the appropriateposition) and covered with a towel. When the delivery is accomplishedand the provider has the baby in their hands, the provider is directedto the warmer, the towel is removed, and the provider is allowed tostart the neonatal resuscitation simulation.

Setting up of the PEDIBIue includes: plugging in the control box,keeping the tubes off to the side, and maintaining clear access to thered bulb in order to control the infant heart rate. In at least oneembodiment, the control box settings for the neonatal resuscitationsimulation are: status=“one” and “test”, condition=“central”,improvement=“20”, and deterioration=“30”. If running a combinationscenario, other equipment includes a fetal monitoring system. Personnelutilized for the simulation includes staff to control the neonatalresuscitation mannequin (i.e., PEDIBIue). Staff member(s) could also beutilized as live actor(s) accompanying the patient to add realism andplay the part of a family member to add stress/distraction/confusion inthe simulation.

Tips to be given to the provider include: a reminder regarding theanteriorly positioned airway of the PEDIBIue, do not clamp the umbilicalcord because it will not come off easily and will likely destroy theability to create the infant's heart rate with the pressure bulb, andlubricate the infant with ultrasound gel to simulate that the infant hasjust delivered, and a reminder to clean and dry the infant. Additionaltips include: place the infant on a wet towel (which also gives theproviders a reminder to dry off the infant), use a smaller endotracheal(ET) tube (e.g., 2.5 mm) for the PEDIBIue neonate, and lubricate the ETtube in order to get it into the mannequin. The providers are alsoreminded that they will be physically controlling the infant's heartrate in the umbilical cord. As a point of reference for the personcontrolling the infant: for a heart rate less than 60 beats per minute(bpm), one squeeze every 1.5-2 seconds; heart rate greater than 60 butless than 100 bpm, one squeeze every 1 second; and, heart rate greaterthan 100 bpm, two squeezes every 1 second.

In an embodiment of the invention, a case flow for the neonatalresuscitation simulation includes setting up the PEDIBIue simulator (asdescribed above), setting up the video camera, and briefing the initialprovider on the clinical scenario. The initial provider enters room (ifrunning a combined simulation, the delivery simulation is conductedfirst); and, the initial provider is told that “the infant is notbreathing” (the infant has apnea and a HR less than 100 bpm). Theparticipant performs bulb suction, dries and stimulates the infant,removes wet linens, and begins positive pressure ventilation with 100%oxygen. At approximately 30 seconds, the infant continues to be apneicand the HR is less than 60 bpm (regardless of interventions). The HR ofless than 60 is continued and the team is allowed to performinterventions (e.g., chest compressions, intubation, and administrationof medications). The providers' questions regarding the infant'sbreathing are answered (infant still has apnea); and, the umbilicalpulse is checked for the actual heart rate. The cyanosis is continuallyreset approximately every 20 seconds by pressing the “Condition Button”three times to go back to “Central Cyanosis”. The infant's heart rate isincreased. The providers are informed that the infant is breathing wellunder the following conditions: it has been approximately 5 minutessince the resuscitation started; and, the team has intubated the infantand administered at least one correct dose/route of epinephrine (e.g.,via ET tube dose is 0.3-1 ml/kg at 1:10,000 concentration). The team isinformed that the scenario is over and the debrief is performed.

The team is not given any more history than what was offered before theyentered into the room. Questions about the breathing are answered; and,the team is continually told that the infant has apnea. If the teamtries to place an umbilical catheter, they are informed that this is notpossible in this simulation.

After the scenario is over, the labeled clickers are handed out to theappropriate staff participants, the CPS system is opened, and thedebrief is loaded for the appropriate scenario. The basic assumption isreviewed with the team; and, the teamwork debriefing is conducted. Afterthe teamwork debriefing, critical actions for the simulation arereviewed with the team. The team members are asked for any lessonslearned, which are recorded so they can be implemented on the labor anddelivery ward if needed. The labor and delivery team is dismissed, theprovider tasks and performance grading for the simulation scenario areopened and reviewed with all of the graders (e.g., 2 physicians and 2nurses who observed the simulation). Both the teamwork debriefing andthe provider tasks and performance grading are exported.

The following are potential factors to consider when scoring theproviders on the neonatal resuscitation simulation: activating theradiant warmer, positioning the infant with the neck slightly extended,attempting to suction the mouth followed by the nose, drying theinfant's body and head, stimulating the infant to breathe, removing wetlinen from contact with the infant, and evaluating respirations, heartrate and color.

Other potential scoring factors include: connecting the bag/mask to theoxygen source and selecting 5 L/min of 100% oxygen, providingsupplemental oxygen, announcing the 1 minute APGAR (Appearance, Pulse,Grimace, Activity, Respiration) score, calling for help (e.g., neonatalintensive care (NICU), US Army Field Manuals staff (FM staff)),correctly positioning the mask on the infant, and beginning ventilationsat the proper rate (e.g., 40-60 breaths/min) and pressure.

Additional scoring factors can include: initially assesses heart rate,breath sounds and chest movement, initially ventilating forapproximately 30 seconds, reevaluating heart rate for approximately 6seconds, beginning chest compressions for a heart rate less than 60 bpm,correctly performing two thumb or two finger chest compressions, propercadence of chest compressions/ventilations (e.g., twocompressions/second, ventilation after every third compression(“one-and-two-and-three-and-breathe-and-one-and-two . . . )), checkingheart rate after approximately 30 seconds of compressions forapproximately 6 seconds, correctly intubating patient withinapproximately 20 seconds of beginning attempt, confirming placement ofthe tube prior to continuing ventilation (e.g., auscultating, observingchest rise, ET tube vapor), securing ET tube properly, and consideringplacement of the umbilical vein catheter. Other potential scoringfactors include: estimating the infant's weight prior to givingepinephrine, checking the dose and concentration of epinephrine beforeadministration, giving epinephrine at the proper dose and concentrationvia the ET tube (e.g., via ET tube dose is approximately 0.3-1 ml/kg atapproximately 1:10,000 concentration), correctly stating to cease chestcompressions based on a heart rate less than 60 bpm, continuing toventilate the infant at the proper rate until help arrives, andannouncing the 5 minute APGAR score.

In at least one embodiment of the invention, potential teaching pointsand critical actions to discuss in debriefing include: the neonatalresuscitation program (NRP) algorithm including positive pressureventilation, demonstration of proper performance of chest compressionsand proper ratio of compressions/ventilations, review of epinephrinedosage, epinephrine concentration and routes of administration, andcrisis resource management skills and TEAMSTEPPs. FIG. 8 illustratessample TEAMSTEPPS debriefing questions according to an embodiment of theinvention.

Other potential critical actions include: warming, positioning, dryingand stimulating the infant, providing positive pressure ventilation forat least 30 seconds before proceeding to more advanced actions (e.g.,chest compressions, intubation, line placement, medications), checkingfor heart rate at the umbilicus (for at least 6 seconds), using oxygenduring the resuscitation (e.g., 5 L of 100% oxygen), and givingcompressions once the heart rate is less than 60 bpm and positivepressure ventilation has not been successful. Additional criticalactions can include: using the proper chest compression technique, usingthe proper ratio of chest compressions/ventilations (e.g., 3:1=90compressions: 30 ventilations per minute), intubating the infant at somepoint during the simulation, considering placement of an umbilical line,and giving the proper dose/concentration of epinephrine before the heartrate rises back above 60 bpm (e.g., 0.01-0.03 mg/kg of 1:10,000, use upto 0.1 mg/kg per ET).

In an embodiment of the invention, the actual simulation itself takesapproximately 5-10 minutes to complete when factoring in the time forthe providers to arrive and perform the NRP. The debriefing takesapproximately 15 minutes followed by another 5-10 minutes to completethe CPS grading. The NRP Code for initial stabilization includes:A—Airway (position and clear), B—Breathing (stimulate to breath), andC—Circulation (assess heart rate and color) Temperature (warm and dry).

Operative Vaginal Delivery for Fetal Distress Simulation

The following description provides a curriculum example for an operativevaginal delivery simulation. One of ordinary skill in the art willappreciate based on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for an operative vaginal delivery forfetal distress simulation involves a 26 year old G2P1001 patient at 38+5weeks gestational age (GA). Her obstetrical history is significant forone previous full-term spontaneous vaginal delivery (SVD) of a 7 lb maleinfant without noted complications. Her current pregnancy has not hadany complications other than being diagnosed with Group B Strepapproximately 3 weeks ago. She has no significant medical or surgicalhistory. She was admitted in active labor and at last check, she wasC/C/+1 station an hour ago. The FHRT had been reassuring, butdecelerations have been occurring and the fetal heart has now been inthe 80s for 3 minutes. An alternate clinical scenario involves a 41 yearold G1 P0 patient at 41+1 weeks GA. She is undergoing an induction oflabor for mild preeclampsia and has had an otherwise uncomplicatedprenatal course. She began pushing approximately 15 minutes ago. Theprovider is called to the room for a fetal heart rate deceleration thathas been less than 90 bpm for nearly three minutes.

The simulator utilized for the operative vaginal delivery example is theNOELLE birthing mannequin with a vacuum delivery fetus although othersimulators could be used. This fetus allows performance of either avacuum or forceps delivery without changing. The vacuum fetus is placedinto the abdomen of the birthing mannequin (the cervix does not have tobe set in place). A fetal monitoring system is utilized to demonstrate aterminal bradycardia during the delivery. In order to do this, afterstarting up the software, the file “Operative Vaginal Delivery TerminalBradycardia” or “Operative Vaginal Delivery Repetitive Decels” isloaded; and, the “Update” button is clicked for the fetal monitors. Thedifference between the two monitoring scenarios is the level of fetaldistress. The terminal bradycardia scenario makes the team move morequickly, whereas the repetitive decels scenario gives the team more timeto counsel the patient. A staff member is utilized to control the fetusand maternal mannequin. Staff member(s) could also be utilized as liveactor(s) accompanying the patient to add realism and play the part of afamily member to add stress/distraction/confusion in the simulation.

The providers may use a vacuum or forceps. Silicone spray lubricant isutilized due to a superior seal with the vacuum device. Alternatively, asmall amount of sonogram gel is utilized. The provider is not permittedto actually perform an episiotomy; however, they are permitted tosimulate one.

In an embodiment of the invention, a case flow for the operative vaginaldelivery for fetal distress simulation includes setting up the NOELLEsimulator, turning on the fetal monitors, loading the scenario, andclicking “Update”. The initial provider is briefed on the clinicalscenario. The providers enter the room and perform a cervicalexamination to recognize fetal distress. The providers counsel thepatient on the indications/risks for an operative vaginal delivery. Ifthey fail to do so, the providers are asked “is that dangerous?” Theproviders are allowed to perform an operative delivery. The fetus ispushed to make it deliver; and, the scenario is ended. The debrief isconducted; and, the technical aspects of the delivery are reviewed withthe individual providers.

If the providers ask for help from pediatrics, they are told that theyare on their way. The providers are not given any more history than whatreceived before they walked into the room. After the scenario is over,the labeled clickers are handed out to the appropriate staffparticipants, the CPS system is opened, and the debrief is loaded forthe appropriate scenario. The basic assumption is reviewed with theteam; and, the teamwork debriefing is conducted. After the teamworkdebriefing, critical actions for the simulation are reviewed with theteam. The team members are asked for any lessons learned, which arerecorded so they can be implemented on the labor and delivery ward ifneeded. The labor and delivery team is dismissed, the provider tasks andperformance grading for the simulation scenario are opened and reviewedwith all of the graders (e.g., 2 physicians and 2 nurses who observedthe simulation). Both the teamwork debriefing and the provider tasks andperformance grading are exported.

The following are potential factors to consider when scoring theproviders on the operative vaginal delivery for fetal distresssimulation: counseling the patient regarding vacuum delivery (withoutprompting), explaining the indication for the procedure, discussingpotential complications (e.g., shoulder dystocia, postpartum hemorrhage,3rd/4th degree lacerations, endometritis, scalp lacerations,cephalohematoma, retinal hemorrhages, and/or neonatal jaundice), askingthe patient if they understand the counseling, and asking the patient ifthey have any questions. Other potential scoring factors include:offering a cesarean section as an alternative, calling for pediatrics,calling for anesthesia, assesses bony pelvis, determining the fetal headposition, assessing the fetal station, ensuring adequate anesthesia, andestimating fetal weight.

Additional scoring factors can include: emptying the bladder, spreadingthe labia and inserting the vacuum device, placing the vacuum cup overthe center of the sagittal suture, checking to ensure that no vaginaltissue is under the vacuum cup, asking for suction to be applied thenrechecking application, asking for the appropriate level of pressure(e.g., approximately 600 mmHg), and applying axis traction in adirection perpendicular to the cup. Other potential scoring factorsinclude: changing the direction of traction upwards as the headdelivers, rechecking for vaginal tissue under the vacuum cup afterreapplication if a pop-off occurs, releasing suction after the head isdelivered, attempting to support the perineum during the delivery of thefetal head, and going to the operating room without considering anoperative vaginal delivery in the delivery room.

Furthermore, the physician may be graded based on the following factors:reaction to the fetal distress in timely manner, performance of thevacuum delivery correctly, performance of the vacuum delivery safely,preparation for the vacuum delivery procedure, overall performanceduring the scenario, and overall counseling of the patient during thescenario.

If forceps are utilized, the providers are also graded based on theiruse. Potential grading factors include: counseling patient regardingforceps delivery (without prompting), offering a cesarean section as analternative, explaining the indication for the procedure, discussingpotential complications (e.g., shoulder dystocia, 3rd/4th degreelacerations, postpartum hemorrhage, endometritis, cephalohematoma,facial nerve injury, facial marks/lacerations, intracranial hemorrhage,and skull fractures). Other potential scoring factors include: askingthe patient if they understand the counseling, asking the patient ifthey have any questions, calling for pediatrics and/or anesthesia,assessing bony pelvis, determining the fetal head position beforeplacing the forceps, assessing the fetal station, ensuring adequateanesthesia, and estimating the fetal weight.

Additional scoring factors for the physicians can include: emptying ofthe bladder, inserting the posterior or maternal left blade first,holding the left forcep with the left hand while using the right hand asa guide without applying excessive force, carrying the left forcepthrough a sweeping arc across the perineum from above, and holding theright forcep with the right hand while the left hand is used as a guidewithout applying excessive force. Other potential scoring factorsinclude: carrying the right forcep through a sweeping arc across theperineum from above, locking the blades, checking the sagittal suture toensure that it is perpendicular to the plane of the shanks, checking theposterior fontanelles to ensure that it is one finger breadth away fromthe plane of the shanks, and checking to see if the head is equidistantfrom the sides of the blades. Other potential scoring factors for thephysician include: ensuring that the fenestrations on each side will notadmit more than one finger, unlocking and readjusting the forceps asnecessary, applying traction with contractions, applying axis tractionin the appropriate manner, changing the axis of traction upward as thehead delivers, attempting to support the perineum, disengaging theforceps in the reverse order of application, and going to the operatingroom without considering an operative vaginal delivery in the deliveryroom. The physician's performance is also graded on the followingpotential factors: safety, preparation, technical performance, overallperformance, and patient counseling.

In at least one embodiment, teaching points and critical actions todiscuss in the debriefing include: understanding the indications andcontraindications for an operative vaginal delivery, conducting anabbreviated counseling of the patient (even in an emergency), and propertechnique in order to decrease the risk of complications. The actualsimulation itself only takes approximately 5-7 minutes to complete.Debriefing takes approximately 10-15 minutes depending on the team'sperformance.

Postpartum Hemorrhage Simulation

The following description provides a curriculum example for a postpartumhemorrhage simulation. One of ordinary skill in the art will appreciatebased on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for a postpartum hemorrhage simulationinvolves a 36 year old G3P2002 patient who had a precipitous delivery.The patient was presented in active labor and rapidly delivered a 4000gram male infant. The placenta just delivered, but she is continuing tohave some bleeding. Oxytocin is running in IV fluids. She does not havea chart available. In an alternate clinical scenario, a 21 year old G1P0patient was delivered by forceps approximately 2 hours ago. Shepresented in spontaneous labor, but required pitocin augmentation forseveral hours prior to needing an operative vaginal delivery for fetaldistress. She had a second degree laceration that was repaired, but shehas soaked a whole pad in the last 15 minutes.

The simulator utilized for the postpartum hemorrhage example is theNOELLE birthing mannequin with the postpartum hemorrhage uterus insertalthough other simulators could be used. Other equipment includes aplastic placenta in the delivery basin on the floor or back table, an IVbag of fluid with the IV line taped to the patient's arm to simulate thefirst IV, and a postpartum hemorrhage insert placed into the NOELLEabdomen on top of the elevating pillow. This allows for it to bepalpated abdominally and then snapped into the perineum. The perineumthat is normally on the mannequin is removed by unsnapping it, inaddition to the foam pad from the abdominal cover (in order to allow forthe trainee to feel the uterus better). The fake blood reservoir isplaced beside the mannequin's head and covered with a towel or sheet(the downstream tubing is clamped off). After filling up the reservoir,the hand pump is connected and the bag is pressurized. The uterus has aseparate hand pump to control firmness. At the beginning of thescenario, the bag is boggy. At the end of the scenario, the bag is firmif the appropriate interventions are performed. A staff member is usedto control hemorrhage and the maternal mannequin. Staff member(s) couldalso be utilized as live actor(s) accompanying the patient to addrealism and play the part of a family member to addstress/distraction/confusion in the simulation.

The mannequin's upper torso is tilted up so that any fake blood thatruns out of the cervix and does not come out the vagina does not collectin the maternal abdomen. A towel or absorbent pad is placed in the upperabdomen by the motor/eclampsia modification piece to ensure that fakeblood does not get into the motor or other mechanical parts. The foampadding is removed from the abdominal cover in order to allow theproviders to feel the boggy uterus better. If the provider tries to do amanual exploration of the uterus, they are informed that they will notbe able to in the simulation, but that the exploration is normal. If theproviders perform a visual inspection of the vagina and if they ask ifthere are cervical lacerations, they are informed that no lacerationsexist. A small amount of fake blood is poured on the pads underneath theperineum.

In at least one embodiment, a case flow/algorithm for the postpartumhemorrhage simulation includes setting up the NOELLE simulator, turningthe fetal monitors on, loading “Postpartum Hemorrhage Initial”, andclicking “Update”. The initial provider is briefed on the clinicalscenario and they enter the room. The bleeding is started (the bag isfilled with approximately 1 L of fake blood); and, the timer is started.The uterus is boggy and not fully inflated. At 30 seconds, “PostpartumHemorrhage 30 SECONDS” is loaded and “Update” is clicked; at 60 Seconds,“Postpartum Hemorrhage 60 SECONDS” is loaded and “Update” is clicked;and, at 120 Seconds, “Postpartum Hemorrhage 120 SECONDS” is loaded and“Update” is clicked. The provider begins assessment and maneuvers.Exemplary maneuvers include: a fundal massage (the uterus remains boggyand bleeding continues), inspection of the cervix/vagina forlacerations, an attempt to manually clear the uterus, and medications(e.g., hemabate, methergine, cytotech). The uterus remains boggy unlessthe provider does the following: perform a fundal massage, assess thecervix for lacerations, and administers two different medicationscorrectly (dose and route). If the medications are given incorrectly(either dose or route), the uterus does not become firm and the bleedingcontinues.

The scenario ends when any of the following occur: (1) a fundal massage,inspection for cervical lacerations, and two medications are givencorrectly, or (2) the blood runs out (takes approximately 5-7 minutes).At this point, the tube allowing the bleeding is clamped and thedebriefing is conducted.

The providers may increase the pitocin rate if requested, but this doesnot have any effect on the scenario (there are approximately 20 units inthe IV bag initially). There are no lacerations seen externally; theproviders may inspect the placenta, which is on the back table. Theplacenta appears intact. If asked for vitals at times other than listedin the case flow, the vitals previously given are restated and/or theproviders are pointed towards the fetal monitors. If asked by theproviders, they are told that the estimated blood loss for the initialdelivery is 500 cc; and, the patient's initial hematocrit was 30%. Theprovider is not allowed to insert a needle through the abdomen in orderto administer medications directly to the uterus as this will puncturethe inflatable uterus. All medication orders (dose and route) areclarified. The provider is not allowed to use notes.

After the scenario is over, the labeled clickers are handed out to theappropriate staff participants, the CPS system is opened, and thedebrief is loaded for the appropriate scenario. The basic assumption isreviewed with the team; and, the teamwork debriefing is conducted. Afterthe teamwork debriefing, critical actions for the simulation arereviewed with the team. The team members are asked for any lessonslearned, which are recorded so they can be implemented on the labor anddelivery ward if needed. The labor and delivery team is dismissed, theprovider tasks and performance grading for the simulation scenario areopened and reviewed with all of the graders (e.g., 2 physicians and 2nurses who observed the simulation). Both the teamwork debriefing andthe provider tasks and performance grading are exported.

The following are potential factors to consider when scoring theproviders on the postpartum hemorrhage simulation: recognizingpostpartum hemorrhage, inspecting the placenta to ensure it appearsintact, inspecting the vagina and cervix for lacerations, andrecognizing that the bleeding is coming from the uterus. Other potentialscoring factors include: performing a fundal massage, administeringmedication to correct atony (e.g., methergine with a correct dose ofapproximately 0.2 mg and a correct route of IM; hemabate with a correctdose of approximately 0.25 mg and a correct route of IM; cytotech(misprostol) with a correct dose of approximately 800-1000 ug with acorrect route per rectum), correcting the hemorrhage prior to the bloodrunning out, and the total amount of time required to correct thehemorrhage. The providers are also graded based on their recognition ofpostpartum hemorrhage in a timely manner, calling for medications in atimely fashion, overall performance, and preparedness.

In at least one embodiment, teaching points and critical actions todiscuss in debriefing include: knowledge of the risk factors forpostpartum hemorrhage, knowledge of the correct doses and routes ofadministration for the medications, ability to execute the criticalactions as outlined in the scoring factors, and knowing the differentialfor postpartum hemorrhage. The actual simulation itself only takesapproximately 5-7 minutes to complete. The debriefing takesapproximately 10-15 minutes depending on the team's performance.

Shoulder Dystocia Simulation

The following description provides a curriculum example for a shoulderdystocia simulation. One of ordinary skill in the art will appreciatebased on this disclosure that specific process steps are forillustration only, and that certain steps may be omitted. Manymodifications and variations will be apparent to those of ordinary skillin the art without departing from the scope and spirit of the invention.

An exemplary clinical scenario for a shoulder dystocia simulationinvolves a 35 year old G2P1001 patient at 41+1 weeks gestation. Herprenatal course has beencomplicated by advanced maternal age (AMA) witha normal amniocentesis and a positive 1 hour glucola with a negative 3hour glucose tolerance test (GTT). She was presented in active labor andwas given an epidural for pain relief and progressed well. She wasC/C/+1 at her last check and has been pushing for approximately 90minutes with a reassuring fetal heart rate tracing. In an alternatescenario, a 21 year old G3P0020 patient is presented at 38+4 weeksgestation. Her prenatal course was complicated by maternal obesity(BMI=31). Her 1 hour glucola was normal and she was presented withspontaneous rupture of membranes (SROM) with clear fluid approximately12 hours earlier and was noted to have irregular contractions. She wasplaced on oxytocin and has progressed to C/C/+2 and feels the urge topush. The fetal heart rate tracing has been reassuring.

The simulator utilized for the shoulder dystocia example is the NOELLEbirthing mannequin with a fetus having a dystocia harness, althoughother simulators could be used. After the fetal head delivers, theproviders keep the rest of the baby from delivering. The staff holdsonto the baby/harness by placing their hand underneath the patient gownand the abdominal cover. Either the staff holds the fetus in by graspingthe body or feet or by using a harness which is wrapped around thefetus. This harness is made of thin and strong material, i.e., a nylonstrap or bungee cord. The posterior arm during the delivery is free tobe delivered. Fetal heart rate monitors are used to demonstrate aterminal bradycardia during the delivery. In order to do this, afterstarting up the software, the file “Shoulder Dystocia” is loaded and the“Update” button for the fetal monitors is clicked. A staff membercontrols the fetus and maternal mannequin. Staff member(s) could also beutilized as live actor(s) accompanying the patient to add realism andplay the part of a family member to add stress/distraction/confusion inthe simulation.

A large amount of lubrication is used for the fetus, e.g., siliconelubricant, sonogram gel. The cervix is removed so that it does not holdup the fetus. The provider is told to only simulate an episiotomy ifthey feel that one is necessary and not to actually cut the mannequin.If a fetal heart rate monitor simulator is utilized, comments such as“the baby is very blue” and “why won't the baby come out” are made tothe providers.

In at least one embodiment, the case flow/algorithm of the shoulderdystocia simulation includes setting up the NOELLE simulator, turning onthe fetal monitors, loading the desired scenario, and clicking “Update”.The initial provider is briefed on the clinical scenario. The providerenters room and is informed that the patient is having a contraction andshe feels that she has to push. The fetal head is pushed until itdelivers. The fetus restitutes such that one fetal shoulder is anterior.Traction is applied on the harness and the shoulders are not allowed todeliver. The timer is started to measure the head-to-body deliveryinterval. The providers recognize the shoulder dystocia and beginmaneuvers. The maneuvers are responded to with feedback if the providersask if the shoulder is delivering. If/when the provider delivers theposterior arm, the fetus is allowed to deliver. If the providers do notattempt to deliver the posterior arm, then the simulation proceeds untilthey do a Zavenelli maneuver or until they inform the graders that theydo not know what else to do. After the scenario ends (either theposterior arm delivers, a Zavenelli maneuver is performed, or theprovider gives up), the timer is stopped and the debriefing isconducted.

The providers are not given any more patient history than what receivedbefore they walked into the room. If the provider pulls hard on theinfant, the staff maintains a tight grip on the cord. If the anteriorfetal shoulder appears during delivering, the staff pulls the infantback further into the pelvis.

After the scenario is over, the labeled clickers are handed out to theappropriate staff participants, the CPS system is opened, and thedebrief is loaded for the appropriate scenario. The basic assumption isreviewed with the team; and, the teamwork debriefing is conducted. Afterthe teamwork debriefing, critical actions for the simulation arereviewed with the team. The team members are asked for any lessonslearned, which are recorded so they can be implemented on the labor anddelivery ward if needed. The labor and delivery team is dismissed, theprovider tasks and performance grading for the simulation scenario areopened and reviewed with all of the graders (e.g., 2 physicians and 2nurses who observed the simulation). Both the teamwork debriefing andthe provider tasks and performance grading are exported.

The following are potential factors to consider when scoring theproviders on the shoulder dystocia simulation: recognizing the shoulderdystocia, calling for additional help (e.g., nurse, physician, and/orpediatrics), applying gentle traction to attempt delivery, performing aMcRobert's maneuver, and utilizing suprapubic pressure. Other potentialscoring factors include: attempting an oblique maneuver (e.g., Woodscrewor Rubin), episiotomy, attempting to deliver the posterior arm, drainingthe bladder, attempting to fracture the clavicle, symphisiotomy,performing a Zavenelli maneuver, collecting cord blood for gases, andthe actual head-to-body delivery time. The provider is also graded basedon: performance of maneuvers in a timely fashion, performance of mostmaneuvers correctly, overall performance, and preparedness.

In at least one embodiment, teaching points and critical actions todiscuss in debriefing include: anticipating shoulder dystocia,understanding and verbalizing risk factors for shoulder dystocia,executing the critical actions as outlined in the scoring factors, andknowing the list of possible maneuvers. The actual simulation itselfonly takes approximately 5-7 minutes to complete. The debrief takesapproximately 10-15 minutes depending on the team's performance.

Accordingly, an embodiment of the invention provides an obstetricssimulation system, comprising an articulating maternal birthingsimulator. The maternal birthing simulator is a full size and full-bodyfemale having an intubeable airway with a chest rise component, aforearm having a medication receiving component, and/or a fetal heartsound component. In an alternative embodiment, the maternal birthingsimulator lacks limbs (i.e., arms and legs). Additionally, the maternalbirthing simulator includes a head descent and cervical dilationmonitor, a placenta positionable in at least two locations, two or moreremovable dilating cervices, and/or postpartum vulval suturing inserts.

As illustrated in FIGS. 9A and 9B, an eclampsia simulation component 910is provided in a cavity 920 of the maternal birthing simulator 930,wherein the eclampsia simulation component 910 has a motor 940, a driveshaft 950 connected to the motor 940, and a cam 960 connected to thedrive shaft 950. FIG. 9B illustrates a side view and FIG. 9C illustratesa top view of the eclampsia simulation component 910. The cam 960engages and agitates an aperture 970 within the cavity 920. The centerof the cam 960 is offset with respect to a center of the aperture 970.Specifically, as illustrated in FIG. 9B, rotation of the drive shaft 950and the resulting movement of the cam 960 moves the cavity 920 to shakethe maternal birthing simulator 930 all around.

At least one processor is provided for receiving input from the maternalbirthing simulator, generating feedback based on the input, and sendingthe feedback to the maternal birthing simulator. The obstetricssimulation system further includes: a medical information (e.g., heartrate, temperature) display connected to the maternal birthing simulator,a video recording and playback system connected to the processor, and/oran audio system connected to the maternal birthing simulator.

Moreover, a grading component is connected to the processor. Asdiscussed more fully above, the CPS debriefing/grading system hasindividual keypads (IR system), labeled keypads, and on-screenanonymity. FIGS. 6A and 6B illustrate an example of on-screen anonymity.Each grader (e.g., Physician 1, Physician 2, Nurse 1, Nurse 2) inputsscores into the system. For example, a scoring factor for the eclampticseizure simulation is whether the provider recognizes the situation asan eclamptic seizure (FIG. 6A; A=Yes, B=No). After all of the gradershave input their scores, the combined scores are displayed, wherein thegraders remain anonymous (FIG. 6B; five graders scored a “Yes”, threegraders scored a “No”). As illustrated in FIG. 6C, reports can beproduced in order to view the scoring input by graders for a specificscoring factor (e.g., “Calls for additional help”).

At least one embodiment of the invention provides a method, includingassembly of a simulation system having a simulator, a processor, and atleast one display. The simulation system is provided along withdocumentation to a plurality of medical facilities within a system.Training on the use of the simulator, different simulations, andcriteria for grading the performance on any given simulation is alsoprovided. The training includes team training for conducting simulationsusing the simulation system. The simulations include breech vaginaldelivery, umbilical cord prolapsed, eclampsia, neonatal resuscitation,operative vaginal delivery, postpartum hemorrhage, and/or shoulderdystocia.

More specifically, the breech vaginal delivery simulation assembles thebirthing mannequin and the birthing fetus in a breech position. Asillustrated in FIG. 10, a medical staff is instructed that a patientfeels pressure and has to push, wherein the patient is a birthingmannequin (item 1010). The simulation observes whether of breechpresentation of a birthing fetus is diagnosed from a cervicalexamination of the birthing mannequin by the medical staff (item 1020).It is further observed whether a delivery preparation is performed bythe medical staff, wherein the delivery preparation includes pushing thehead of the birthing fetus until a buttocks of the birthing fetus beginsto deliver in a sacrum anterior position (item 1030). The simulationobserves whether delivery maneuvers are performed by the medical staff(item 1040). The delivery maneuvers are responded to with feedbackduring the simulation (item 1050). The medical staff is debriefed (item1060) and graded based on observations and predetermined scoringcriteria (item 1070).

The umbilical cord prolapse simulation assembles the birthing mannequinand a mobile cart having a touch-screen monitor. As illustrated in FIG.11, the medical staff is instructed that a patient's water has broken,wherein the patient is the birthing mannequin (item 1110). Thesimulation observes whether the medical staff recognizes distress of thebirthing fetus on the touch-screen monitor (item 1120) and observeswhether the medical staff responds to the distress (item 1130). If themedical staff waits for a vaginal delivery, the birthing fetus is keptwithin the abdomen of the birthing mannequin (item 1140). The simulationobserves whether the medical staff transfers the birthing mannequin tothe operating room (item 1150). The medical staff is debriefed (item1160) and graded based on observations and predetermined scoringcriteria (item 1170).

The eclampsia simulation assembles the birthing mannequin and mobilecart with at least one touch-screen monitor. The birthing mannequin hasa means for shaking to simulate a generalized seizure (e.g., theeclampsia simulation component). As illustrated in FIG. 12, the medicalstaff is instructed that a patient has had a headache and it is gettingworse, wherein the patient is the birthing mannequin (item 1210).Moreover, the medical staff is instructed that the patient's bloodpressure is increasing (item 1220). A simulated eclamptic seizure isinitiated by the simulator (item 1230); and, the medical staff isobserved for whether or not they perform assessment and intervention ofthe simulated eclamptic seizure (item 1240). The intervention includesadministrating medications and/or rolling the patient. The simulatedeclamptic seizure is continued (item 1250). The medical staff isdebriefed (item 1260) and graded based on observations and predeterminedscoring criteria (item 1270).

The neonatal resuscitation simulation assembles the birthing mannequinand the baby simulator. As illustrated in FIG. 13, the medical staff isobserved for recognition that the baby simulator is not breathing andhas a heart rate less than 100 beats per minute (item 1310). Thesimulation observes: whether the medical staff performs bulb suction,drying and stimulation of the baby simulator, removal of wet linens, andpositive pressure ventilation with oxygen (item 1320), and whether themedical staff recognizes that the baby simulator continues to not breathand the heart rate is less than 60 beats per minute (item 1330).Moreover, the medical staff is observed for whether or not they performinterventions, such as, for example, chest compressions, intubation,and/or administration of medications (item 1340). The simulation alsoobserves: whether the medical staff examines an umbilical pulse for anactual heart rate (item 1350), and whether the medical staff recognizesthat the baby simulator is breathing and the heart rate has increased iffive minutes have passed since the performance of the bulb suction andthe medical staff has intubated the baby simulator and administered atleast one dosage of epinephrine (item 1360). The medical staff isdebriefed (item 1370) and graded based on observations and predeterminedscoring criteria (item 1380).

The operative vaginal delivery simulation assembles the birthingmannequin, the mobile cart with at least one touch-screen monitor, and avacuum delivery fetus, which allows a vacuum delivery or a forcepsdelivery. As illustrated in FIG. 14, the medical staff is observed forwhether or not they perform a cervical examination and recognizedistress of the fetus (item 1410). The simulation also observes: whetherthe medical staff counsels the patient on indications and risks of anoperative vaginal delivery (item 1420) and whether the medical staffperforms the operative vaginal delivery (item 1430). The fetus is pushedto facilitate the operative vaginal delivery (item 1440). The medicalstaff is debriefed (item 1450) and graded based on observations andpredetermined scoring criteria (item 1460).

The postpartum hemorrhage simulation assembles the birthing mannequinwith a postpartum hemorrhage uterus insert, and the mobile cart with atleast one touch-screen monitor. As illustrated in FIG. 15, bleeding ofthe birthing mannequin is simulated (item 1510); and, the uterus of thebirthing mannequin is not allowed to fully inflate (item 1520). Thesimulation observes whether the medical staff performs assessments andmaneuvers (item 1530). The maneuvers include a fundal massage,inspection of the cervix and/or vagina for lacerations, manual clearingof the uterus, and/or administration of medications. If the maneuversinclude the fundal massage, the simulating of the bleeding continues(item 1540). The medical staff is debriefed (item 1550) and graded basedon observations and predetermined scoring criteria (item 1560).

The shoulder dystocia simulation assembles the birthing mannequin andmobile cart with at least one touch-screen monitor. As illustrated inFIG. 16, the medical staff is informed that the patient is having acontraction and feels that she has to push, wherein the patient is thebirthing mannequin (item 1610). The head of the fetus is pushed untilthe head delivers (item 1620); and, the fetus is restituted, wherein theshoulder of the fetus is anterior (item 1630). Traction on a harness isapplied and the shoulder is not allowed to deliver (item 1640). A timeris activated to measure the head-to-body delivery interval (item 1650).The simulation observes whether the medical staff recognizes shoulderdystocia and performs maneuvers (item 1660). Maneuvers are responded towith feedback (item 1670). If the medical staff delivers a posterior armof the fetus, the fetus is allowed to deliver (item 1680). If themedical staff does not deliver the posterior arm of the fetus, themedical staff is allowed to perform a Zavenelli maneuver or discontinuedelivery (item 1690). The timer is stopped (item 1692); and, the medicalstaff is debriefed (item 1694) and graded based on observations andpredetermined scoring criteria (item 1696). Specifically, the grading ofthe medical staff is based on at least five of the following factors:recognition of shoulder dystocia, calling for help from at least one ofa nurse, a physician, and pediatrics, applying gentle traction toattempt delivery, performing a McRobert's maneuver, utilizing suprapubicpressure, attempting an oblique maneuver, episiotomy, attempting todeliver a posterior arm, draining a bladder, attempting to fracture aclavicle, symphisiotomy, performing a Zavenelli maneuver, collectingcord blood for gases, actual head-to-body delivery time, performance ofmaneuvers in a timely fashion, performance of maneuvers correctly,overall performance, and preparedness.

The terminology used herein is for the purpose of describing particularembodiments only and is not intended to be limiting of the invention. Asused herein, the singular forms “a”, “an” and “the” are intended toinclude the plural forms as well, unless the context clearly indicatesotherwise. It will be further understood that the terms “comprises”and/or “comprising,” when used in this specification, specify thepresence of stated features, integers, steps, operations, elements,and/or components, but do not preclude the presence or addition of oneor more other features, integers, steps, operations, elements,components, and/or groups thereof.

1-4. (canceled)
 5. An obstetrics simulation system, comprising: anarticulating maternal birthing simulator; and an eclampsia simulationcomponent in a cavity of said maternal birthing simulator, saideclampsia simulation component comprising: a motor, a drive shaftconnected to said motor, a cam connected to said drive shaft, whereinsaid cam engages and agitates an aperture within said cavity, andwherein a center of said cam is offset with respect to a center of saidaperture.
 6. The obstetrics simulation system according to claim 5,further comprising: at least one processor for receiving input from atleast one of said maternal birthing simulator and an articulatingdelivery fetus, generating feedback based on said input, and sendingsaid feedback to at least one of said maternal birthing simulator andsaid delivery fetus; a medical information display connected to saidmaternal monitoring system and said fetus monitoring system; and agrading component connected to said processor.
 7. The obstetricssimulation system according to claim 6, further comprising a videorecording and playback system connected to said processor.
 8. Theobstetrics simulation system according to claim 6, further comprising anaudio system connected to at least one of said maternal birthingsimulator and said articulating delivery fetus.
 9. The obstetricssimulation system according to claim 5, wherein said maternal birthingsimulator comprises at least one of a full size full-body female, anintubeable airway comprising a chest rise component, a forearmcomprising a medication receiving component, a fetal heart soundcomponent, a head descent and cervical dilation monitor, a placentapositionable in at least two locations, at least two removable dilatingcervices, and postpartum vulval suturing inserts.
 10. A method,comprising: assembly of a simulation system having a simulator, aprocessor, and at least one display; providing said simulation systemalong with documentation to a plurality of medical facilities within asystem; and providing training on said use of said simulator, differentsimulations, and criteria for grading said performance on any givensimulation. 11-14. (canceled)
 15. The method according to claim 10,wherein said simulations comprise an eclampsia simulation comprising:instructing a medical staff that a patient has had a headache and isgetting worse, wherein said patient comprises a birthing mannequin;instructing said medical staff that said patient's blood pressure isincreasing; initiating a simulated eclamptic seizure by said simulator;observing whether said medical staff performs assessment andintervention of said simulated eclamptic seizure, said interventioncomprising at least one of administrating medications and rolling ofsaid patient; continuing said simulated eclamptic seizure; debriefingsaid medical staff; and grading said medical staff based on observationsand predetermined scoring criteria.
 16. The method according to claim15, wherein said assembly comprises assembly of said birthing mannequinand a mobile cart comprising at least one touch-screen monitor, whereinsaid birthing mannequin comprises a means for shaking to simulate ageneralized seizure. 17-22. (canceled)
 23. The method according to claim10, wherein said simulations comprise a shoulder dystocia simulationcomprising: informing a medical staff that a patient is having acontraction and feels that she has to push, wherein said patientcomprises a birthing mannequin; pushing a head of a fetus until saidhead delivers; restituting said fetus, wherein a shoulder of said fetusis anterior; applying traction on a harness and disallowing saidshoulder to deliver; activating a timer to measure a head-to-bodydelivery interval; observing whether said medical staff recognizesshoulder dystocia and performs maneuvers; responding to said maneuverswith feedback; if said medical staff delivers a posterior arm of saidfetus, allowing said fetus to deliver; if said medical staff does notdeliver said posterior arm of said fetus, allowing said medical staff toone of perform a Zavenelli maneuver and discontinue delivery; stoppingsaid timer; debriefing said medical staff; and grading said medicalstaff based on observations and predetermined scoring criteria.
 24. Themethod according to claim 23, wherein said assembly comprises assemblyof said birthing mannequin and a mobile cart comprising at least onetouch-screen monitor.
 25. The method according to claim 10, wherein saidtraining includes team training for conducting simulations using saidsimulation system.
 26. A method for simulating a medical procedure,comprising: assembling a simulation system comprising a birthingmannequin, a birthing fetus, a processor, and at least one display;providing a medical staff with a pre-simulation clinical scenario;beginning a simulated medical procedure, comprising activating saidsimulation system; observing behavior of said medical staff; reacting tosaid behavior with feedback from said simulation system; observing aresponse to said feedback from said medical staff; ending said simulatedmedical procedure; and debriefing and grading said medical staff basedon said behavior, said response, and predetermined scoring criteria. 27.The method according to claim 26, wherein said simulated medicalprocedure comprises a breech vaginal delivery, wherein said providing ofsaid medical staff with said pre-simulation clinical scenario comprisesinstructing said medical staff that a patient feels pressure and has topush, wherein said patient comprises said birthing mannequin, andwherein said observing of said behavior comprises: observing whether ofa breech presentation of said birthing fetus is diagnosed from acervical examination of said birthing mannequin by said medical staff,observing whether a delivery preparation is performed by said medicalstaff, wherein said delivery preparation comprises pushing a head ofsaid birthing fetus until a buttocks of said birthing fetus begins todeliver in a sacrum anterior position, and observing whether deliverymaneuvers are performed by said medical staff.
 28. The method accordingto claim 26, wherein said simulated medical procedure comprises anumbilical cord prolapsed, wherein said providing of said medical staffwith said pre-simulation clinical scenario comprises instructing saidmedical staff that a patient's water has broken, wherein said patientcomprises said birthing mannequin, and wherein said observing of saidbehavior comprises: observing whether said medical staff recognizesdistress of said birthing fetus on said display, observing whether saidmedical staff responds to said distress, and observing whether saidmedical staff transfers said birthing mannequin to an operating roomwhen said birthing fetus remains within an abdomen of said birthingmannequin.
 29. The method according to claim 26, wherein said simulatedmedical procedure comprises an eclampsia simulation, wherein saidproviding of said medical staff with said pre-simulation clinicalscenario comprises instructing said medical staff that a patient has hada headache and is getting worse and that said patient's blood pressureis increasing, wherein said patient comprises said birthing mannequin,and wherein said observing of said behavior comprises observing whethersaid medical staff performs assessment and intervention of a simulatedeclamptic seizure, said intervention comprising at least one ofadministrating medications and rolling of said patient.
 30. The methodaccording to claim 26, wherein said simulated medical procedurecomprises a neonatal resuscitation, and wherein said observing of saidbehavior comprises: observing whether said medical staff recognizes thata baby simulator of said simulation system is not breathing and has aheart rate less than 100 beats per minute; observing whether saidmedical staff performs bulb suction, drying and stimulation of said babysimulator, removal of wet linens, and positive pressure ventilation withoxygen, observing whether said medical staff recognizes that said babysimulator continues to not breath and said heart rate is less than 60beats per minute, observing whether said medical staff performsinterventions, said interventions comprising at least one of chestcompressions, intubation, and administration of medications, observingwhether said medical staff examines an umbilical pulse for an actualheart rate, and observing whether said medical staff recognizes thatsaid baby simulator is breathing and said heart rate has increased iffive minutes have passed since said performance of said bulb suction andsaid medical staff has intubated said baby simulator and administered atleast one dosage of epinephrine.
 31. The method according to claim 26,wherein said simulated medical procedure comprises an operative vaginaldelivery, and wherein said observing of said behavior comprises:observing whether said medical staff performs a cervical examination andrecognizes distress of said birthing fetus, observing whether saidmedical staff counsels a patient on indications and risks of anoperative vaginal delivery, and observing whether said medical staffperforms said operative vaginal delivery.
 32. The method according toclaim 26, wherein said simulated medical procedure comprises apostpartum hemorrhage simulation, and wherein said observing of saidbehavior comprises observing whether said medical staff performsassessments and maneuvers, said maneuvers comprising at least one of afundal massage, inspection of at least one of a cervix and vagina forlacerations, manual clearing of said uterus, and administration ofmedications.
 33. The method according to claim 26, wherein saidsimulated medical procedure comprises a shoulder dystocia simulation,wherein said providing of said medical staff with said pre-simulationclinical scenario comprises instructing said medical staff that apatient is having a contraction and feels that she has to push, whereinsaid patient comprises said birthing mannequin, and wherein saidobserving of said behavior comprises observing whether said medicalstaff recognizes shoulder dystocia and performs maneuvers.
 34. Themethod according to claim 26, wherein said grading of said medical staffcomprises grading based on at least five of the following factors:recognition of shoulder dystocia, calling for help from at least one ofa nurse, a physician, and pediatrics, applying gentle traction toattempt delivery, performing a McRobert's maneuver, utilizing suprapubicpressure, attempting an oblique maneuver, episiotomy, attempting todeliver a posterior arm, draining a bladder, attempting to fracture aclavicle, symphisiotomy, performing a Zavenelli maneuver, collectingcord blood for gases, actual head-to-body delivery time, performance ofmaneuvers in a timely fashion, performance of maneuvers correctly,overall performance, and preparedness.